RESEARCH

Alarm fatigue and the implications for patient safety

Fadiga de alarmes e as implicações para segurança do paciente
Fatiga de alarmas y las implicaciones para la seguridad del paciente

Adriana Elisa Carcereri de OliveiraI, Adrielle Barbosa MachadoI,

Edson Duque dos SantosI, Érika Bicalho de AlmeidaI
I
Faculdade de Ciências Médicas e da Saúde de Juiz de Fora. Juiz de Fora, Minas Gerais, Brazil.

How to cite this article:

Oliveira AEC, Machado AB, Santos ED, Almeida EB. Alarm fatigue and the implications for patient safety.
Rev Bras Enferm [Internet]. 2018;71(6):3035-40. DOI: [Link]

Submission: 06-25-2017 Approval: 05-01-2018

ABSTRACT
Objective: To measure the response time of health professionals before sound alarm activation and the implications for patient safety.
Method: This is a quantitative and observational research conducted in an Adult Intensive Care Unit of a teaching hospital. Three
researchers conducted non-participant observations for seven hours. Data collection occurred simultaneously in 20 beds during the
morning shift. When listening the alarm activation, the researchers turned on the stopwatches and recorded the motive, the response time
and the professional conduct. During collection, the unit had 90% of beds occupied and teams were complete. Result: We verified that
from the 103 equipment activated, 66.03% of alarms fatigued. Nursing was the professional category that most provided care (31.06%)
and the multi-parameter monitor was the device that alarmed the most (66.09%). Conclusion: Results corroborate the absence or delay
of the response of teams, suggesting that relevant alarms might have been underestimated, compromising patient safety.
Descriptors: Nursing; Critical Care; Clinical Alarms; Biomedical Technology; Patient Safety.

RESUMO
Objetivo: Mensurar o tempo-resposta dos profissionais de saúde diante ao disparo dos alarmes sonoros e as implicações para a segurança
do paciente. Método: Pesquisa quantitativa, observacional, em uma Unidade de Terapia Intensiva Adulto de um Hospital de Ensino.
Os três pesquisadores realizaram observações não participativas durante 7 horas. A coleta de dados ocorreu simultaneamente em 20
leitos no período diurno. Ao ouvir o disparo, os pesquisadores acionavam os cronômetros e registravam o motivo, o tempo-resposta e
a conduta profissional. Durante a coleta a unidade estava com 90% dos leitos ocupados e as equipes estavam completas. Resultados:
Verificamos que, dos 103 equipamentos disparados, 66,03% dos alarmes fatigaram. A enfermagem foi a categoria profissional que
mais atendeu (31.06%), e o monitor multiparâmetros alarmou (66,09%). Conclusão: Os resultados corroboram a ausência ou retardo
de resposta da equipe, sugerindo que alarmes relevantes tenham sido menosprezados, comprometendo a segurança dos pacientes.
Descritores: Enfermagem; Cuidados Críticos; Alarmes Clínicos; Tecnologia Biomédica; Segurança do Paciente.

RESUMEN
Objetivo: Mensurar el tiempo-respuesta de los profesionales de salud delante del disparo de las alarmas sonoras, y las implicaciones
para la seguridad del paciente. Método: Investigación cuantitativa, observacional, en una Unidad de Terapia Intensiva – Adulto de un
hospital de enseñanza. Los tres investigadores han realizado observaciones no participativas durante 7 horas. La recogida de los datos
ha ocurrido simultáneamente en 20 camillas en el período diurno. Al oír el disparo, los investigadores accionaban los cronómetros y
registraban el motivo, el tiempo-respuesta y la conducta profesional. Durante la recogida, la unidad estaba con el 90% de las camillas
ocupadas y los equipos estaban completados. Resultados: Certificamos que, de los 103 equipamientos que han sido disparados, el
66,03% de las alarmas han fatigado. La enfermería ha sido la categoría profesional que más ha atendido (el 31,06%), y el monitor
multiparámetros ha alarmado (el 66,09%). Conclusión: Los resultados han corroborado la ausencia o el retardo de la respuesta del
equipo, sugiriendo que las alarmas relevantes hayan sido menospreciadas, comprometiendo la seguridad de los pacientes.
Descriptores: Enfermería; Cuidados Críticos; Alarmas Clínicas; Tecnología Biomédica; Seguridad del Paciente.

CORRESPONDING AUTHOR Érika Bicalho de Almeida E-mail: ebicalhoenf@[Link]

[Link] Rev Bras Enferm [Internet]. 2018;71(6):3035-40. 3035

 Alarm fatigue and the implications for patient safety
Oliveira AEC, Machado AB, Santos ED, Almeida EB.

INTRODUCTION Fora (FCMS/JF), in compliance with Resolution 466/2012 of the

Brazilian National Health Council. The inclusion of research-
In Intensive Care Units (ICU), the main causes of noises are ers in the field promoted the familiarization with the reality to
related to equipment with acoustic alarms, whose objective be investigated and brought closer the potential participants
is to alert the multiprofessional team on the alterations in the for the presentation of the research proposal and later invita-
monitoring of patients, or even on its malfunction(1). tion to participate. Those who accepted signed the informed
Regarding electromedical equipment, the complexity of con- consent form.
figuration, programming and intervention of alarm systems for the
management of the team was evidenced(2). Failures of these equipment Study design, location, and period
in intensive therapy, associated with adverse events, are portrayed in This is an observational and descriptive research with quan-
literature as a potentially serious factor for patient safety(3). titative approach held at an Adult ICU with 20 beds of a public
For many professionals in the healthcare team, alarms are teaching hospital, located in a municipality of the Southeastern
commonly seen as expendable due to the high incidence of false region of Brazil.
positives, that is, without clinical importance. The longer the Data collection occurred in June 2016. During seven hours
time of intervention, the higher will be the degree of risk for the of observation in the morning shift, three researchers simultane-
patient’s health, reducing his/her safety during hospitalization. ously collected the data in 20 beds previously distributed among
Alarm fatigue is the implication of a resistance/desensitization them, with a mean of 1 hour of observation per day for seven
in the perception of alarm signaling. Knowing how to decipher days. We chose this strategy to evaluate the largest number of
what was signaled by the sound of the device and understanding alarms activated concomitantly. The methodological option for
the profile of clinical importance represented by such activa- the day shift was due to the familiarity of the researchers with
tion determines the stimulus-response time, which is crucial the team, which did not occur in night shifts.
to characterize if there is alarm fatigue or not(4).
When a large number of alarms are activated at the same time, Population or sample; inclusion and exclusion criteria
suppressing other clinically significant alarms and allowing some The response time of healthcare teams to the alarms activated
relevant ones to be silenced, disabled or ignored by health profes- by electromedical equipment and the conducts adopted by pro-
sionals, the occurrence of alarm fatigue is verified. Absence of fessionals were evaluated. It is noteworthy that the composition
responses to relevant signals suggests impairment on safety and of the healthcare team of the ICU fulfills the existing legisla-
worsens the clinical conditions of patients in intensive therapy(5). tion and that, at the time of data collection, each professional
In Brazil, with the implementation of the National Policy of category was complete. Therefore, every professional of the
Patient Safety (Política Nacional de Segurança do Paciente), the healthcare team was observed.
institutions are encouraged to create new protocols besides those As for human resources, during daytime shifts (from 7:00
suggested by the program, aiming at promoting safety culture, am to 7:00 pm), the nursing staff consists of two nurses and ten
risk management and especially patient safety(6). technicians, two doctors and two physical therapists. There is
Recent data from the Emergency Care Research Institute (Ecri), always a resident doctor on duty.
which is specialized in patient safety and use of electromedical Inclusion and exclusion criteria for the response time of the
equipment, point that, between 2012 and 2014, alarms had the healthcare team to the alarms were: a) inclusion criteria: alarms
first place among the ten health technology hazards, due the con- activated by a multi-parameter monitor, mechanical ventilator
secutive notifications of incidents related to alarms with patients and continuous infusion pump; b) exclusion criteria: alarms
hospitalized in the United States(7). In 2017, the concern with the considered inconsistent caused by manipulation during the
increase in adverse events related to alarms continued occupying procedures performed on patients.
the third place in the ranking list released by the Ecri(8-9).
Given these worrying data, our research is justified by the need Study protocol
to discuss the relationship between alarm fatigue and patient safety. Data collection occurred as follows: when hearing the the
This discussion will allow the proposal of improvements to the alarm activation, researchers turned on the stopwatches and
health care of the multiprofessional team and provide prevention unobtrusively moved to the beds, watching carefully not only
strategies that ensure patient safety in healthcare institutions. the sound and visual signals of the electromedical device, but
also the conduct of health professionals before the alarms. They
OBJECTIVE timed the response time of the team and recorded the profes-
sional’s conduct for data analysis. To this end, each researcher
To measure the response time of health professionals before took a position at strategic locations, not to generate bias in
sound alarm activation and the implications for patient safety. the research result. The agreement was that, once the timing
was initiated, in case a second alarm was activated, the latter
METHOD would be ignored. When arriving at the sector, the noise level
was measured in decibel (dBA) with the aid of a sound level
Ethical aspects meter and with a software for this equipment installed on the
The study was approved by the Research Ethics Committee mobile device.
of the Faculdade de Ciências Médicas e da Saúde de Juíz de

Rev Bras Enferm [Internet]. 2018;71(6):3035-40. 3036

 Alarm fatigue and the implications for patient safety
Oliveira AEC, Machado AB, Santos ED, Almeida EB.

Analysis of results and statistics arterial pressure (AP), with 37 times (36.7%), followed by peripheral
For analysis, the frequency and percentage descriptive statistics oxygen saturation (SpO2), 17 (16.5%), and heart rate (HR), 10 (9.7%).
was used to organize, summarize and describe the important The second electromedical device with more frequency
aspects of a set of characteristics observed for the variables: was the continuous infusion pump, with a total of 25 times
a) inconsistent alarm; b) silenced the alarm; c) assessed and (24.27%), of which 22 (21.35%) were due to lack of medica-
conducted intervention; d) fatigued alarm. tion, and of these, 5 (4.8%) fatigued. The device with the lowest
incidence of activation was the mechanical ventilator, with 8
RESULTS (7.76%) alarms, given that 4 (3.88%) were due to high peak
pressure, 3 (2.91%) to positive airway pressure, and 1 (0.97)
During data collection, a total of 103 activations was identi- to expiratory flow.
fied. The mean occupancy rate of the unit was 90% of the beds. Table 4 shows the conduct adopted by the healthcare team
The teams were complete. when attending the alarm. Given the activation, 17 (16.5%)
Table 1 shows the number of alarms attended by each pro- health professionals evaluated and performed some kind of
fessional category and the mean time spent by professionals. intervention for the benefit of the patient. The professionals
Nursing staff was the category that most attended the alarms silenced the alarms in 16 attendances (15.53%), and 5 (4.85%)
activated, with 31.06%. Subsequently, there were nursing tech- were defined as inconsistent alarms, without clinical relevance.
nicians (29.12%) and nurses (1.94%); 2.91% of alarms were
attended by other professionals within the multidisciplinary team.
Table 3 – Electromedical devices that activated the alarm,
We verified that 66.03% of alarms investigated fatigued, and
Juiz de Fora, Minas Gerais, Brazil, 2016
determined that no professionals attended these cases, which
remained sounding for more than 10 minutes. Electromedical Number of alarms Mean response
devices (%) time
Table 1 – Professional category that attended the alarms from CIP 24.27 05:10
electromedical devices, Juiz de Fora, Minas Gerais, MM 66.09 09:21
Brazil, 2016 MV 08.73 06:51

Note: CIP – continuous infusion pump; MM – multi-parameter monitor; MV –

Number of alarms Mean time
Professional category mechanical ventilator.
attended (%) (min)

Nursing technician 29.12 3:40 Table 4 – Conducts that professionals had before the alarm
Nurse 1.94 2:04 activated, Juiz de Fora, Minas Gerais, Brazil, 2016
Physical therapist 1.94 1:04
Number of alarms Mean response time to
Doctor 0.97 3:45 Conducts
(%) the alarm (min)

FA 66.03 10:26
IA 4.85 03:27
Table 2 – Factors that generated alarm activation, Juiz de
API 16.50 03:33
Fora, Minas Gerais, Brazil, 2016 SA 15.53 03:33

Note: FA – fatigued alarm; IA – inconsistent alarm; API – assessed and per-

Physiological Number of alarms Mean response
formed intervention; SA – silenced alarm.
variables (%) time

HR 9.70 09:57 DISCUSSION

AP 36.07 08:50
SpO2 16.50 10:02 In the ICU investigated, the parameters are measured in a
KVO (medication) 24.27 05:10 standardized form, i.e. the same physiological values are con-
Peak P 3.88 03:54 sidered for all patients admitted to the unit, regardless of their
PAP 1.94 06:31
pathology or need. Results of recent studies present similar
Exp Flow 0.97 11:00
Loose Electrode 5.82 09:28 characteristics, signaling that the findings on patient safety also
involve reflection on the impact of the inclusion of technolo-
Note: HR – heart rate; PA – arterial pressure; SpO2 – peripheral oxygen saturation; gies in critical care environments, due to the standardization
KVO – end of continuous pump infusion; Peak P – peak pressure; PAP – positive
airway pressure; Exp Flow – expiatory flow. of parameters of electromedical devices(10-12).
Our noteworthy findings suggest significant risks of occur-
rence of adverse events with patients observed, because more
Tables 2 and 3 show the factors that generate the sound alarms than 66% of the alarms were recorded without response, with
identified and the devices that promoted alarm activation the most, response time over 10 minutes, and less than 26% of the alarms
respectively. The electromedical device that activated the most was were attended in less than 5 minutes.
the multi-parameter monitor, with a total of 68 times (66.09%); In 2014, a study conducted in Brazil in an ICU similar to
among the factors observed, the one that activated the most the was our research showed that if these alarms signaled a tachycardia

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 Alarm fatigue and the implications for patient safety
Oliveira AEC, Machado AB, Santos ED, Almeida EB.

or tachypnea in patients with sepsis, they could impair the non-infusion(17-18). Another study identified an alarm activation
prognosis. In a second example, if the alarms indicated a severe for 15 minutes without anyone verifying what was happening
arrhythmia or instability, the lack or delay of the team’s response and, in another situation, a professional silenced the alarm
to the alerts would result in serious consequences on patients’ professional and did not communicate the healthcare team(9).
clinical conditions, since the changes would not be detected, It is known that the medication process is complex and
preventing the adoption of appropriate therapeutic measures, characterized by the practice of several professionals marked
which could impact the patient safety(11). by fragility. It becomes necessary to raise awareness of nurses
Regarding the cardiopulmonary resuscitation maneuvers, a about the training of the healthcare team on inappropriate
time limit of 10 minutes was mentioned based on the guide- handling of equipment, allowing the discussion of strategy that
lines of the American Heart Association. From the pathophysi- promotes quality in care(10,17-18).
ological point of view, after 10 minutes of the beginning of Another important data from the study was the low number
cardiopulmonary arrest, in case the resuscitation maneuver of alarms generated by the mechanical ventilator, represent-
is not initiated, inflammatory cytokines, free radicals and cell ing 8.73% of the activations, with only one effective service
damage are released, causing myocardial changes, sometimes performed by the nursing staff. The mechanical ventilator is
irreversible (stone heart), and severe neurological dysfunction(13). one of the main life support resources used in ICU. Mechani-
Hence, with the objective of promoting patient safety, and cal ventilator means using a machine that replaces, totally or
avoiding possible clinical complications as well as alarm fa- partially, the patient’s respiratory activity, with the objective of
tigues, it becomes necessary to emphasize the importance of restoring the balance between supply and demand of oxygen
alarms and review the time professionals take to attend them. (O2), decreasing the respiratory workload of patients on ven-
In addition, we emphasize the need of health professionals tilatory failure(19-20).
thinking the importance of risk management related to technol- In a study conducted in 2013, which evaluated alarm fatigue
ogy, especially those which provide advanced life support in in electromedical devices, researchers found that no alarm from
intensive care unit(14). mechanical ventilators was fatigued because most of activations
In data analysis, we noted that the multi-parameter monitor of the device had short duration, some up to 4 seconds. It was
activated in 66% of times on average, with mean activation noticeable, in the environment researched, that the sound of
time of approximately 9 minutes. Our results show that the the mechanical ventilator draws more attention, and that health
parameters, the programming and the volume of alarms from professionals demonstrate greater reaction to this alarm when
multi-parameter monitors, as well as the configuration of physi- compared to others. Although these alarms were not fatigued,
ological variables, should be adopted as routine in the ICU, due to their large number, they significantly compete to the
pondering the patient under severe conditions depends on fatigue of other alarms(1).
this technological device for both diagnostic and therapeutic Alarms from the mechanical ventilator are intended to warn
purposes as well as for improvement of his/her safety. With the healthcare team on any hemodynamic alteration in the pa-
this practice, quality of care is promoted, which echoes in tient. For the appropriate use of this technology, alarms should
the teamwork process(15-16). Such conducts decrease the noise, be adjusted and managed by the team, aiming at providing a
providing a less stressful environment. safe care. Therefore, on the part of professionals, knowledge
The concern with the conduct before clinical alarms is present about the possible causes of activation and about the outcome
in several publications, among which we highlight the findings of for the patient is mandatory given that the response time of the
the study in which researchers measured the stimulus-response multiprofessional team, when ineffective, suggests a multifaceted
time of a team to the alarms of multi-parameter monitors in a problem because it involves human factors, equipment, alarm
coronary care unit. More than 60% of the alarms were considered devices and components of the workflow(11).
to be fatigued, and less than 20% were attended within 10 min- Another serious issue to consider is the noise level in units.
utes(10). In another investigation study on the stimulus-response Our research showed that the decibel mean was 75 dBA, i.e.
time of the team to alarms activated due to the monitor, during approximately 66.6% above the level recommended: the Bra-
monitoring of invasive blood pressure, there was a record of 76 zilian Association of Technical Standards (ABNT – Associação
alarms, of which 21 were attended with mean response time of Brasileira de Normas Técnicas) establishes 45 dBA as the ac-
2 min and 45 seconds. The 55 remaining alarms were defined ceptable limit of sound level in internal environments(21). The
as fatigued by the authors because there was no response on findings suggest that alarm fatigue associated with the high
the part of professionals(17). level of noises found in the institution contributes to lack of
The research indicated that part of the healthcare team is concentration, stress and decrease of the attention of healthcare
desensitized to the alarm caused by continuous infusion pump, team, leading to an environment susceptible to considerable
because more than 24.27% of the activations had no inter- risks and compromising patient safety(7).
vention. Studies show that approximately 30% to 60% of all As for human resources, results evidenced few procedures
harmful mistakes with intravenous medication are related to the adopted with regard to adjustment of monitors, programming
continuous infusion pump. Many of these mistakes occur during and measurement of patients’ vital parameters, correction of the
the programming, especially in the adjustment of the infusion continuous infusion pump infusion, and verification as well as
speed and when the professional despises the alarm activation, correction of parameters of mechanical ventilators. Such con-
which can cause excessive medication, overdose and even the ducts demand professional knowledge to evaluate the patient’s

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 Alarm fatigue and the implications for patient safety
Oliveira AEC, Machado AB, Santos ED, Almeida EB.

clinical condition and the parameterization of electromedical For the effective response to alarms, a training with realistic
devices individually and according to its pathology. simulation in educational institutions is necessary, with quar-
In this regard, studies show that there is a prevalence in terly periodicity, both in subjects directed to critical patients at
the lack of adherence of teams, factor determined by the lim- undergraduate courses as lato sensu specialization classes . In
ited interdisciplinary training, directed to programming and addition, there must be a previous training and preparation of
configuration of alarms, generating little awareness on the health professionals to the correct handling of equipment and for
urgency of attending the alarms. This can be one of the factors actions on patient safety through permanent education centers in
that contribute to the occurrence of routine violations and that services, with approaches that involve everyday situations in the
result in adverse events(2,11,22). ICU. This attitude will probably decrease the number of adverse
In this respect, it is important for the healthcare team to be events and will consequently encourage a patient safety culture.
attentive to the mutual work, cooperating for interdisciplinary
knowledge and enabling the process of communication in pre- CONCLUSION
vention of incidents. For thus, the premise of communicational
competence in ICU is mandatory, allowing the organization, The results of the research corroborate the absence or delay
identification and establishment of goals; in addition to the of the response of the healthcare team before the monitoring
solution of problems focused in increasing the efficiency of sound alarms in the ICU, suggesting that relevant alarms might
the work unit and its complete organization(23). have been underestimated, thus compromising patient safety.
The variables of the study indicate that patient safety has
Study limitations direct correlation with the correct handling of electromedical
The fact that the data was collected in only one center and equipment, alarm systems and human resources. Noting that
that there is a possibility of Hawthorne effect regarding the the unit investigated had no protocol for parameterization of
presence of researchers can be cited as limitations of this study. devices and management of risks related to alarm fatigue, the
index of fatigued alarms in the service is a matter of concern. It
Contributions to the fields of nursing and health is worth emphasizing that nursing was the professional category
We emphasize the importance of managing alarms in ICU that most attended the alarms, suggesting the desensitization
because the problem permeates from the social environment to of other professionals to the activations.
the economic costs and financial implications. Therefore, the The technological device in the ICU has as function to alert
maturation of the team is mandatory regarding the knowledge, professionals about potential alterations in both devices and
interpretation, clinical reasoning and scientific decision making patients, promoting the alarm activation. Therefore, it is impera-
with ethical attitudes, promoting quality in service and especially tive for the multidisciplinary team to understand its importance
putting into practice care proposals focused on patient safety. and to become more attentive to the signs.

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